In North America, a significant proportion of the growing physician workforce comprises international medical graduates (IMGs). Currently, they represent about a quarter of all practicing physicians.1–4 IMGs have played a valuable role in providing care, particularly during times of relative physician shortage.4 However, controversy exists regarding whether differences in IMG medical education, or in social and cultural norms affect the quality of patient care. Studies have demonstrated conflicting results when comparing the quality of care of IMGs versus domestically trained graduates. IMGs have lower board or specialty exam certification pass rates.5,6 Patients of those IMGs who passed but had lower test scores experienced an increased adjusted risk of harm.7 Yet, when comparing the care received from IMGs with domestic graduates among a similar cohort of hospitalized patients, the same group of investigators found no differences in mortality.8 Similarly, Ko et al9 found no differences in the quality of care of acute myocardial infarction patients between IMGs and domestic graduates.
Physician professional misconduct is an important aspect of patient safety and quality of care. Results from physician disciplinary proceedings have been used as a surrogate measure of professional misconduct in previous studies.10–13 Although only a small proportion of physicians are disciplined,10 each case of physician misconduct has the potential to cause adverse patient outcomes.10,12 To date, there is a paucity of data on professional misconduct amongst IMG physicians. Thus, we sought to better understand the characteristics of disciplined IMG physicians through evaluation of a retrospective nationwide cohort of disciplined physicians.
We conducted a retrospective cohort study to compare the rate and nature of disciplined offenses and penalties among IMGs versus North American medical graduates (NAMGs). We identified all Canadian physicians who were disciplined between January 1, 2000, and May 31, 2015.
Physician disciplinary proceedings are publicly available on the College of Physicians and Surgeons Web sites for each province in Canada. After receiving ethical approval from both St. Michael’s research ethics board (Toronto, Ontario, Canada) and Mt. Sinai Hospital research ethics board (Toronto, Ontario, Canada), we gathered data on all disciplined physicians. We collected demographic information, including location of practice, gender, type of practice license, medical specialty, year of graduation, and country and school of medical school graduation. The total years of practice were also obtained for each physician: the time frame, in years, between obtaining a medical degree and the year of disciplinary action. We categorized graduates as NAMGs if they graduated from a medical school in the United States or Canada, or as IMGs if they graduated from a medical school in any other country.
Similar to previous studies, we grouped all disciplinary proceedings into one or more of the following 11 categories: standard-of-care issues, inappropriate prescribing, unlicensed activity/breech of registration condition, unprofessional conduct, sexual misconduct, mental illness, self use of drugs and alcohol, fraudulent behavior/prevarication, conviction of a crime, unclear allegation, and miscellaneous findings.10–13 The penalties imposed on each disciplined physician were documented under one or more of the following categories: revocation, surrender, suspension, restriction, retraining/course/assessment required, psychotherapy/counseling/substance abuse/professional support, formal reprimand, other action, and fine/cost.10–13 We also recorded the length of suspension, fine amount, and cost amount. We compared all demographic, disciplinary, and violation findings between NAMGs and IMGs. When demographic information or violation and penalty details were not available online, we accessed the Canadian Medical Directory (1970–2015)14 or contacted the respective College of Physicians and Surgeons directly through e-mail correspondence to accurately obtain this information.
Online data for the years prior to 2007 were not available for the provinces of New Brunswick, Prince Edward Island, and Newfoundland & Labrador. In addition, online data were unavailable prior to 2002 for the province of Alberta. We excluded cases of discipline against residents and for which physicians’ specific identifying data and medical school location were unavailable.10–13
Determination of physician years for IMG and NAMG physicians
We compiled the total number of IMGs practicing in Canada between 2000 and 2015 from publicly available data from the Canadian Institute for Health Information (CIHI).15 Physician data for 2015 had not been published at the time of our analyses and, as a result, could not be used when computing the case rate data. Thus, for case rate data, we used the entire physician population data available between 2000 and 2014. We calculated estimated case rates per 10,000 physician years, where a physician year represents a single year in which a single physician was known to be practicing in Canada during the study period. In other words, if there were 100 physicians practicing for 5 years each, then our exposure is 500 physician years. The top four countries of MD graduation for foreign-trained physicians were determined using information from both CIHI15 and Scott’s Medical Database,14 between 2006 and 2014, as these were the only consecutive years to report full datasets on IMG numbers. For both the overall and by-country analyses, we calculated discipline rates by dividing the number of cases by the relevant number of physician years. As discipline cases are rare relative to the number of physician years, all rates were then multiplied by 10,000 for interpretability.
For binary demographic variables and case-level outcomes we calculated the sample proportions for IMGs and NAMGs along with the Fisher exact test P value against no association. For the variable “number of professional years at the time of first offense” we calculated the mean and standard deviation (SD) for IMGs and NAMGs along with the t test P value against equality of means. For case rate analyses, we used generalized linear models to estimate case rates (standardized to cases per 10,000 physician years) and rate ratios, with 95% confidence intervals (CIs). For all comparisons, we calculated the standardized rate for each group along with 95% CIs, the estimated rate difference, and the Wald test P value against a true rate difference of zero. We calculated risk ratios (RRs) and 95% CIs for select outcomes. Alpha = .05 is used as the threshold for statistical significance. All analyses were performed using R statistical software, version 3.0.2 (R Foundation for Statistical Computing, Vienna, Austria).
During the study period, the mean number of practicing IMG physicians was 15,440 per year; this constituted a mean (SD) of 23.4% (1.1%) of all physicians per year. Throughout this period, there were 794 physicians disciplined in 922 different disciplinary cases. IMGs constituted about a third of disciplined physicians (264; 33.2% of all cases) and were responsible for a similar proportion of discipline cases (303; 32.9%). During the study period, there were 33 (12.5%) IMG physicians who were each disciplined on multiple occasions, similar to 68 (12.8%) NAMG physicians. The majority of disciplined IMGs (241; 91.3%) and NAMGs (487; 91.9%) were male. The mean number of years of practice before being disciplined was 32.8 years (SD = 10.9) for IMGs and 28.5 years (SD = 11.1) for NAMGs. A greater proportion of IMGs disciplined were anesthesiologists compared with NAMGs (P = .01) (Table 1). The top 10 countries of medical school origin for IMGs who were disciplined over the study period are depicted in Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A388.
The overall disciplinary rate for all physicians was 8.52 cases per 10,000 physician years (95% CI [7.77, 9.31]). The discipline rate per group was higher for IMGs than for NAMGs (12.91 [95% CI (11.50, 14.43)] vs. 8.16 (95% CI [7.53, 8.82] cases per 10,000 physician years, P < .01), RR 1.58 (95% CI [1.38, 1.82]). The yearly estimated discipline rates were significantly higher for IMGs compared with NAMGs in 7 out of 15 of the years studied and were never significantly lower (Table 2). IMGs were less likely than NAMGs to be disciplined for inappropriate prescribing (P = .03) but more likely to be disciplined for fraudulent behavior (P = .01) (Table 3). IMGs were more likely than NAMGs to be penalized with retraining/assessment by their professional college (P = .02) (Table 4). Three of the top four IMG countries of medical school origin had significantly higher overall discipline rates than for NAMGs. These were South Africa (RR 1.73 [95% CI (1.14, 2.51)], P < .01), Egypt (RR 3.59 [95% CI (2.18, 5.52)], P < .01), and India (RR 1.66 [95% CI (1.01, 2.55)], P = .03) (Table 5).
Approximately one-third of disciplined physicians in Canada between 2000 and 2015 were IMGs, higher than the mean overall composition of IMGs in the Canadian population per year during this time frame. This corresponded to a higher rate of discipline in 7 of the 15 individual years of study. The majority of disciplined IMGs and NAMGs were male and were in practice for approximately 30 years prior to disciplinary action. IMGs from South Africa, Egypt, and India were also more likely to be disciplined than NAMGs.
Previous studies have investigated the characteristics of disciplined physicians; however, to our knowledge, few have done so through an evaluation of a nationwide cohort of physicians who have been disciplined. Elkin et al16 evaluated complaints and disciplinary findings amongst IMGs in two specific regional cohorts in Australia and found that IMGs were more likely to attract complaints to medical boards and have adverse disciplinary findings than their Australian-trained counterparts. Other studies have also demonstrated an increased likelihood of discipline amongst foreign-trained physicians.17,18 Yet, others have shown no significant correlation.19–21
Whereas Elkin et al16 investigated the frequency of complaints and disciplinary action of IMGs, there was no description of the specific violations committed or the specific penalties imposed. Our data provide more detail in showing that of our study cohort, IMGs were less likely to be disciplined for inappropriate prescribing but more likely to be disciplined for fraudulent behavior. They were also more likely than NAMGs to be required to undergo retraining/assessment by their respective professional college.
Several potential explanations for an increased likelihood of disciplinary action in this population have been proposed. Previous discussions have revolved around the notion that IMGs may possess poorer communication skills, especially if they are from non-English-speaking nations.22 In addition, they may not be used to various cultural norms, which may make communicating effectively—both within a professional team and with patients—more difficult.23 In North America, a more patient-centered approach to care (as opposed to physician-centered or paternalistic) has been emphasized in the last two decades. This communication style encourages the patient to play a more active role in her or his medical decision-making process and involves increased discussion and consideration of the patient’s perspective.24 When an IMG has trained in a country where such an approach is not the cultural norm, differences in expectations between physicians and patients may lead to patient dissatisfaction.25 Perhaps a lack of effective communication skills and familiarity with cultural nuances could increase the risk of patient complaints, leading to disciplinary action. Similarly, specific cultural differences of business ethical practices may explain why IMGs tend to be disciplined for specific reasons (inappropriate prescribing, etc.). Yet within our study cohort, IMG physicians were disciplined, on average, almost 33 years after graduation from medical school—often well after they would have moved countries. In addition, a large proportion of IMGs disciplined were from the United Kingdom, where cultural norms and communication are similar to North America. Therefore, it is unlikely that lack of communication and cultural differences alone explain our findings. However, some of these individuals may not have been practicing in North America for that entire period of time—they may have practiced in a home nation for some duration of those years prior to coming to North America. Unfortunately, a limitation of our data was that we were not able to determine when they began to practice in Canada.
Another explanation is that systemic discrimination may exist within the discipline process for IMG physicians, making them more likely to receive disciplinary action than NAMGs. Indeed, a recent report noted that IMGs appear overrepresented in disciplinary decisions and concluded that some IMG physicians may be treated unfairly.26 Coombs and King,27 through a survey of almost 2,000 physicians in Massachusetts, reported that 44% of U.S. medical graduates believed that their IMG colleagues suffer from significant discrimination within the workplace. Similarly, Neiterman and Bourgeault28 examined the same issues through semistructured qualitative interviews with IMG nurses and physicians in Canada. From that study, IMG physicians reported more concern with discrimination against them by other physicians than in comparison with nurses. It should be further noted that many provincial regulatory authorities are made up of physician colleagues in addition to other important members of the community.28 Further, discrimination against IMGs has been identified in the selection process for U.S. residency programs.29–32 It is possible that a similar type of systemic discrimination may pervade throughout the medical disciplinary system ranging from initial complaint to disciplinary penalty. Confirming its presence, delineating the exact nature of this discrimination, and determining how it may pervade our disciplinary system will take further detailed study.
We found that physicians trained in South Africa, Egypt, and India and practicing in Canada were disciplined at a higher rate than NAMGs during the study period. The estimated discrepancy in rates is unlikely to be due to chance. This study was not powered to make broad generalizations about IMGs from those countries; however, the trend is worth noting and could inform future research. It is notable that all licensed Canadian physicians, regardless of what country they originate from, have the same resources available to them for obtaining legal representation without direct payment as members of the Canadian Medical Protection Agency.33 In addition, we emphasize that although the RRs among the certain countries examined above are higher than for the NAMG population, the overall rate of discipline among the entire IMG physician population is exceedingly low.
We acknowledge several limitations to our study. Information regarding disciplinary findings of IMGs in some areas and during some periods was unavailable and excluded from our study. However, these were relatively small jurisdictions over short time periods, and their inclusion likely would not have changed our findings substantively. Physicians whose names were not made publicly available resulted in missing demographic information and were excluded from our study. However, this was a small proportion of the total number of physicians (24/794 [3.0%] of total physicians). Because there were no data available for the number of complaints that led to disciplinary action, we can only report on the number of physicians who had been disciplined by professional colleges in Canada. Similarly, we cannot comment on complaints and issues resolved through other nonprovincial regulatory bodies (hospital complaint boards, etc.). Further, although we present data for years from medical school graduation to discipline, we were unable to present information on when the IMG physicians began practicing in Canada as discussed above. Finally, our data only include location of medical school graduation and do not include information on locations of other training that may also affect our findings—including residency and other independent practice locations. However, on balance, we believe that the limitations do not invalidate our main findings. Similarly, we recognize that country of medical school graduation is not synonymous with the ethnic or cultural identity of the physician. Accordingly, it should be emphasized that only the geographical location of where the physicians in question graduated from medical school is being examined by these results—not their ethnic or cultural identities.
In summary, we found that IMGs were disciplined more frequently than domestic medical school graduates. Currently, specific targets for intervention remain unclear; however, given that instances of patient complaints (and subsequent disciplinary action) may be related to poorer communication skills and misunderstanding of cultural norms, we propose that educational interventions that target improved communication in the IMG population may minimize, at least in part, episodes of misconduct and disciplinary action. We also propose a formal evaluation to determine whether discrimination exists against IMGs in the medical disciplinary system. In this current climate of relative physician shortage, IMGs will remain an integral part of providing medical care. In the interest of patient safety and improved quality of care, it should be a priority to better understand this phenomenon and, ideally, take measures to prevent misconduct among this important subgroup of physicians.
1. Ranasinghe PD. International medical graduates in the US physician workforce. J Am Osteopath Assoc. 2015;115:236241.
2. Monavvari AA, Peters C, Feldman P. International medical graduates: Past, present, and future. Can Fam Physician. 2015;61:205208, 214.
3. Akl EA, Mustafa R, Bdair F, Schünemann HJ. The United States physician workforce and international medical graduates: Trends and characteristics. J Gen Intern Med. 2007;22:264268.
4. Islam N. The dilemma of physician shortage and international recruitment in Canada. Int J Health Policy Manag. 2014;3:2932.
5. Norcini JJ, Boulet JR, Whelan GP, McKinley DW. Specialty board certification among U.S. citizen and non-U.S. citizen graduates of international medical schools. Acad Med. 2005;80(10 suppl):S42S45.
6. Andrew RF. How do IMGs compare with Canadian medical school graduates in a family practice residency program? Can Fam Physician. 2010;56:e318e322.
7. Norcini JJ, Boulet JR, Opalek A, Dauphinee WD. The relationship between licensing examination performance and the outcomes of care by international medical school graduates. Acad Med. 2014;89:11571162.
8. Norcini JJ, Boulet JR, Dauphinee WD, Opalek A, Krantz ID, Anderson ST. Evaluating the quality of care provided by graduates of international medical schools. Health Aff (Millwood). 2010;29:14611468.
9. Ko DT, Austin PC, Chan BT, Tu JV. Quality of care of international and Canadian medical graduates in acute myocardial infarction. Arch Intern Med. 2005;165:458463.
10. Alam A, Klemensberg J, Griesman J, Bell CM. The characteristics of physicians disciplined by professional colleges in Canada. Open Med. 2011;5:e166e172.
11. Alam A, Khan J, Liu J, Klemensberg J, Griesman J, Bell CM. Characteristics and rates of disciplinary findings amongst anesthesiologists by professional colleges in Canada. Can J Anaesth. 2013;60:10131019.
12. Alam A, Kurdyak P, Klemensberg J, Griesman J, Bell CM. The characteristics of psychiatrists disciplined by professional colleges in Canada. PLoS One. 2012;7:e50558.
13. Liu JJ, Alam AQ, Goldberg HR, Matelski JJ, Bell CM. Characteristics of internal medicine physicians disciplined by professional colleges in Canada. Medicine (Baltimore). 2015;94:e937.
14. Canadian medical directory [1970–2014]. 1970–2014.Toronto, Ontario, Canada: Scott’s Directories.
15. Supply, distribution and migration of Canadian physicians [2000–2014]. 2000–2014. Ottawa, Ontario, Canada: Canadian Institute for Health Information; https://secure.cihi.ca/estore/productSeries.htm?locale=en&pc=PCC34
. Accessed June 21, 2016.
16. Elkin K, Spittal MJ, Studdert DM. Risks of complaints and adverse disciplinary findings against international medical graduates in Victoria and Western Australia. Med J Aust. 2012;197:448452.
17. Khaliq AA, Dimassi H, Huang CY, Narine L, Smego RA Jr. Disciplinary action against physicians: Who is likely to get disciplined? Am J Med. 2005;118:773777.
18. Kohatsu ND, Gould D, Ross LK, Fox PJ. Characteristics associated with physician discipline: A case–control study. Arch Intern Med. 2004;164:653658.
19. Tamblyn R, Abrahamowicz M, Dauphinee D, et al. Physician scores on a national clinical skills examination as predictors of complaints to medical regulatory authorities. JAMA. 2007;298:9931001.
20. Cunningham W, Crump R, Tomlin A. The characteristics of doctors receiving medical complaints: A cross-sectional survey of doctors in New Zealand. N Z Med J. 2003;116:U625.
21. Morrison J, Wickersham P. Physicians disciplined by a state medical board. JAMA. 1998;279:18891893.
22. Dahm MR, Yates L, Ogden K, Rooney K, Sheldon B. Enhancing international medical graduates’ communication: The contribution of applied linguistics. Med Educ. 2015;49:828837.
23. Hall P, Keely E, Dojeiji S, Byszewski A, Marks M. Communication skills, cultural challenges and individual support: Challenges of international medical graduates in a Canadian healthcare environment. Med Teach. 2004;26: 120125.
24. Roter D. The enduring and evolving nature of the patient–physician relationship. Patient Educ Couns. 2000;39:515.
25. McGrath P, Henderson D, Tamargo J, Holewa HA. Doctor–patient communication issues for international medical graduates: Research findings from Australia. Educ Health (Abingdon). 2012;25:4854.
26. Belluz J. Is Canada discriminating against foreign-trained doctors? Macleans Magazine. April 2012. http://www.macleans.ca/society/health/is-canada-discriminating-against-foreign-trained-doctors/
. Accessed June 21, 2016.
27. Coombs AA, King RK. Workplace discrimination: Experiences of practicing physicians. J Natl Med Assoc. 2005;97:467477.
28. Neiterman E, Bourgeault IL. The shield of professional status: Comparing internationally educated nurses’ and international medical graduates’ experiences of discrimination. Health (London). 2015;19:615634.
29. Desbiens NA, Vidaillet HJ Jr. Discrimination against international medical graduates in the United States residency program selection process. BMC Med Educ. 2010;10:5.
30. Moore RA, Rhodenbaugh EJ. The unkindest cut of all: Are international medical school graduates subjected to discrimination by general surgery residency programs? Curr Surg. 2002;59:228236.
31. Nasir LS. Evidence of discrimination against international medical graduates applying to family practice residency programs. Fam Med. 1994;26:625629.
32. Balon R, Mufti R, Williams M, Riba M. Possible discrimination in recruitment of psychiatry residents? Am J Psychiatry. 1997;154:16081609.
33. Sears K, Stockley D, Broderick B. Influencing the Quality, Risk and Safety Movement in Healthcare. 2015.Burlington, VT: Ashgate Publishing Limited.